The CDC Strategic Plan for TBI:

Highlighting Work on Sports Concussion,

Return to Learn, and Return to Play

National Center for Injury Prevention and Control

Division of Unintentional Injury Prevention

CDR Matt Breiding, PhD

Traumatic Brain Injury Team Lead

October 22, 2015

Overview

Outline current CDC strategic direction

Highlight Work on Sports Concussion

Surveillance

Highlight Work Related to Return to Play and

Return to Learn

AssureWidespread

Adoption

The Public Health

Approach to

Prevention

Develop & Test Prevention Strategies

Identify Risk and Protective

Factors

Define the Problem

(Surveillance)

Strategic Directions

Four Pillars

1. Improving the understanding of the

public health burden of TBI

2. Reducing the incidence of TBI

through primary prevention

3. Improving the recognition and

management of mild TBI

4. Improving health outcomes of

persons living with TBI

Strategic Directions

Four Pillars

1. Improving the understanding of the

public health burden of TBI

2. Reducing the incidence of TBI

through primary prevention

3. Improving the recognition and

management of mild TBI

4. Improving health outcomes of

persons living with TBI

ED visits:

450,000 in 2012;

325,000 among ages 0-19

Highest Numbers:

What do we know?

Girls Boys

Playground Football

Bicycling Bicycling

Soccer Playground

Basketball Basketball

Horseback Riding Baseball

Source: Coronado, et al., 2015

At the high school level:

Highest Rates: Boys football, ice hockey, lacrosse

Next: Girls lacrosse, soccer, basketball

Higher rates for girls in gender-comparable sports

Mechanism

Competition vs. Practice

Higher risk for certain positions

What do we know?

Source: Marar, et al., 2012

What is unknown?

Overall incidence and trends

Leading contributors

Proportion experienced in: Organized, school-based sports vs.

Organized, non-school-based sports vs.

Non-organized sports and rec activites.

Healthcare utilization patterns

Surveillance

RECOMMENDATION 1

“The Centers for Disease Control and

Prevention, taking account of existing

surveillance systems and relevant

federal data collection efforts, should

establish and oversee a national

surveillance system to accurately

determine the incidence of sports-

related concussions…”

Institute of Medicine (IOM) and National Research Council (NRC). 2014.

Sports-related concussions in youth: Improving the science, changing the

culture. Washington, DC: The National Academies Press.

Institute of Medicine (IOM) and National Research Council (NRC). 2014.

Sports-related concussions in youth: Improving the science, changing the

culture. Washington, DC: The National Academies Press.

Ages 5 to 21

Demographic information

Pre-existing conditions

Concussion history

Use of protective equipment

and impact monitoring devices

Data on the cause, nature, and

extent of the injury event

Surveillance – Parameters Requested

Evaluation Criteria

Breadth

National level

Representative

Coverage of ages 5-21

Captures concussion outside of: Organized sports

Healthcare setting

Depth

High level of detail Pre-event

Event

Post-event

Clinical Presentation

Other Criteria

Capture TBI more broadly Beyond sports/recreation-related concussions Older age groups

Ability to produce state-level estimates

Developing a Plan to Address the IOM Report Recommendation

Met internally to evaluate

current and new data

systems

Consulted with internal CDC

surveillance experts

Identified candidate methods

Consulted with external

sports concussion

surveillance experts

Surveillance Landscape

NEISS

New Survey

Various Methodologies

Advantages

National, representative, ages 5 to 21

Capable of capturing concussions

• Outside of healthcare setting

• Outside of organized sports

Possible to get high level of detail

Limitations

Self or Parent report

Declining response rates

CDC’s Plan

Development of a new telephone survey

Survey parents/caregivers about their

children’s recent history of head

injuries and associated symptoms

Potentially survey adults regarding their

recent TBI history

Our Plan

Breadth

Full age range

Capture concussions outside of healthcare setting

Capture concussions outside of organized sports

Capture recreation-related concussions

Potential to capture TBI more broadly

Depth

Can collect detailed information

Capable of adding modules

Our Plan

Over the next 2 years

Questionnaire development

Development of sampling

strategy

Cognitive testing of

questionnaires

Pilot study

After that……

Funding/Resources

Ongoing nature of surveillance

Significant Congressional interest

$5 million in President’s FY16 budget

Meeting with partners

Strategic Directions

Four Pillars1. Improving the understanding of the

public health burden of TBI

2. Reducing the incidence of TBI

through primary prevention

3. Improving the recognition and

management of mild TBI

4. Improving health outcomes of

persons living with TBI

Sports Culture

The NCAA and NFSHSA, in

conjunction with the CDC, HRSA,

NATA, and DOE should:

“develop, implement, and evaluate the

effectiveness of largescale efforts to

increase knowledge about concussions

and change the culture (social norms,

attitudes, and behaviors) surrounding

concussions among elementary school

through college-age youth and their

parents, coaches, sports officials,

educators, athletic trainers, and health

care professionals.”

Institute of Medicine (IOM) and National Research Council (NRC). 2014.

Sports-related concussions in youth: Improving the science, changing the

culture. Washington, DC: The National Academies Press.

Strategic Directions

Four Pillars1. Improving the understanding of the

public health burden of TBI

2. Reducing the incidence of TBI

through primary prevention

3. Improving the recognition and

management of mild TBI

4. Improving health outcomes of

persons living with TBI

Heads Up Key Accomplishments

Developed relationships with 85+ organizations and dozens of key experts.

Created over 50 products.

Distributed more than 4 million print resources.

Trained 3 million+ coaches.

20,000+ Facebook fans.

215 million+ media impressions through print media and TV PSAs.

Pediatric Mild TBI Guidelines

Importance of appropriate diagnosis of children and teens with mild TBI.

Need for evidence-based guidelines to help U.S. clinicians treating children and teens.

Workgroup established with over 40 experts.

6 clinical questions, over 12,000 abstracts and 1,700 full-text articles reviewed.

Release expected in 2016.

Six Clinical Questions

1. Do specific tools as compared with a reference standard, accurately

diagnose mild TBI?

2. How often does routine head imaging identify important intracranial

injury?

3. Which features identify patients at risk for important intracranial injury?

4. What factors identify patients at increased risk for ongoing impairment,

more severe-symptoms, or delayed recovery?

5. Which factors identify patients at increased risk of long-term (>1 year)

sequelae?

6. For mild TBI (with ongoing symptoms) which treatments improve mild

TBI-related outcomes?

Translation and Dissemination

Update CDC’s Heads Up

Development of screening tools

Create clinical decision support modules

Work with states to partner with large healthcare organizations

Survey HCPs following release

Youth Sports Concussion Legislation

Three common components:

Education for coaches, parents, and student-athletes

Removal-from-Play

Return-to-Play

Youth Sports Concussion Legislation, United States,

2009

CO

HI

Law includes 3 components of Education,

Removal from play and Return-to-play (2)

CA

IA

MN

NE

MTND

SD

MI

VTME

IN

KY

ID

NVUT

AZNM

TX

OK

WY

ILOH

PA

WV

SC

TN

AR

MSAL

VA

NJ

NC

GA

FL

NY

MD

NH

MA

DE

CTRI

MOKS

AK

LA

WI

WA

OR

CO

Law includes variation of 3

components but not all (2)

Youth Sports Concussion Legislation, United States,

2014

CA

IA

MN

NE

MTND

SD

MI

VTME

IN

KY

ID

NVUT

AZNM

TX

OK

WY

ILOH

PA

WV

SC

TN

AR

MSAL

VA

NJ

NC

GA

FL

NY

MD

NHMA

DE

CTRI

MOKS

AK

LA

WI

WA

OR

CO

HILaw includes 3 components of Education,

Removal from play and Return-to-play

(48)

Law does not speficially include all 3

components of Education, Removal from

Play, and Retun to Play (2)

Significant Variation in Legislation

Coverage

Public and/or private

Age Level of School

Penalties

Coaches training required

Return to Learn guidance

Health care provider

Do they specify?

Do they identify the need for specific training?

Minimum time of removal to play

Who is responsible for content development?

New RTL/RTP Policy Evaluation

Develop a database of RTP

policy elements

Conduct an implementation

evaluation of RTL requirements

Return to Play Evaluation Study

In coordination with USYSA

Compare RTP policies

Athletes and Parents will report weekly on any

concussions experienced

Followup regarding RTP without symptoms

Strategic Directions

Four Pillars1. Improving the understanding of the

public health burden of TBI

2. Reducing the incidence of TBI

through primary prevention

3. Improving the recognition and

management of mild TBI

4. Improving health outcomes of

persons living with TBI

New Report to Congress

TBI Reauthorization Act of 2014 reauthorizes CDC’s traumatic brain injury programs for years 2015-2019

Directs CDC to produce a Report to Congress on the management of TBI in children

In consultation with NIH

Working with 2 external authors

Broad group of stakeholders on external panel

Aim for release in late 2016

For more information please contact Centers for

Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-

6348

E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not

necessarily represent the official position of the Centers for Disease Control

and Prevention.